Provider Demographics
NPI:1124678354
Name:PIC WISCONSIN SC
Entity type:Organization
Organization Name:PIC WISCONSIN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR CREDENTIALING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-653-0130
Mailing Address - Street 1:9701 W HIGGINS RD STE 270
Mailing Address - Street 2:
Mailing Address - City:ROSEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60018-4703
Mailing Address - Country:US
Mailing Address - Phone:847-653-0130
Mailing Address - Fax:
Practice Address - Street 1:19165 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-6076
Practice Address - Country:US
Practice Address - Phone:847-653-0130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care